NR 326-Mental Health Plan Assessment and Clinical Facility Patient Assignment.

NR 326-Mental Health Plan Assessment and Clinical Facility Patient Assignment. HPI (History of Present Illness): This client is from the Washington D.C. school system. In school, he reportedly had a history of acting out, defiant behaviour, bulling, and destruction of school property. In 2015, he threw a rock at a teacher, hitting her in the head. At this point DR was referred to Devereux, FL. It was stated that he made significant progress during this period. However, upon his return home, a sexual allegation was made against DR. The court found him incompetent, but was returned to Devereux GA, to, in the judge’s words, “achieve competency. At this point, his court case is still pending. His stay at Devereux is scheduled to end on 12/31/17. DR has stated the he will be “hurt” if he doesn’t return to the streets in Washington DC Past psychiatric history (include inpatient and outpatient): As mentioned, DR was in residential treatment in Devereux FL. His previous diagnoses from the Washington DC school board included: Depressive anxiety, mood disorder, mixed expressive receptive disorder, and borderline intellectual disability. His current stay in Devereux GA, is court supported, mentioned above. His current diagnoses are somewhat different, including: Oppositional defiant disorder, ADHD, and moderate intellectual disability. DR has had mental health services beginning at five years old Family Psychiatric History: DR’s family history has a paternal gap, and no maternal issues are listed in the charts. DR has a maternal cousin in prison Social History / Psychosocial Assessment: DR lives in a three person household, including his mother, and grandmother. He has no listed siblings; the chart states his mother is unemployed. His family is not religious, and doesn’t appear to be involved in any community services. Staff states DR is friendly, outgoing, and makes Tobacco use? NO Illicit Drug use? YES Frequency/amount: claimed about once every six weeks Alcohol use? YES Frequency/amount: claimed about once every six weeks CAGE Questionnaire, if applicable: N/A Item YE S N O Have you ever felt you should cut down on your drinking? 1 0 Have people annoyed you by criticizing your drinking? 1 0 Have you ever felt bad or guilty about your drinking? 1 0 Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)? 1 0 TOTAL SCORE Physical Assessment: Vital Signs: Time: 10/04/17 Temp: 98.0 F Pulse: 59 BP: 108/80 Resp Rate: 16 O2 sat: 98% O2 delivery: N/A (room air) Pain: 0 Pain reassessment: N/A reassessment time: N/A Physical Assessment Documentation Integumentary Respiratory HEENT GI/GU Cardiac Musculoskeletal Neuro Sleep Patterns: DR has no specific documentation on the above. Visually, he appears within normal limits, displaying no obvious physical difficulties during a physical education activity. He was oriented to place, person, and situation, and spoke at an appropriate developmental level, in terms of vocabulary and speech pattern. Labs: All within normal limits except:  Segmental Neutrophils 39.0 mEq (40 – 74) must be noted that DR was mugged prior to returning to Devereux. Unfortunately, there isn’t any supplemental information regarding this incident. DRAFT Complete CIWA, if applicable and attach 1. What is the client’s primary mental health diagnosis? Other concurrent diagnoses? Describe signs and symptoms currently exhibited that support this diagnosis. Document both subjective and objective assessment information. The nursing student had an opportunity to interact with DR in a group setting and a physical education class totaling about an hour and fifteen minutes. This allows for a more nuanced assessment than from the medical record alone. The primary diagnosis for DR is oppositional defiant disorder, current with ADHD and moderate intellectual disability. As it may be assumed he is on his prescribed medication, DR appeared to interact with his peers in an appropriate manner, in an activity he clearly enjoyed. A clear discrepancy from the chart was DR’s height and weight, which was described as the bottom ten percent. This has clearly changed as he appears to be closer to the median for his age. DR asked relevant and thoughtful questions of the nursing students, in an appropriate manner. It must be noted that DR required seclusion in late September. His observed behaviour was consistent with the chart, in that he seems to do well in the structured and safe environment of Deveraux. Implicitly, it seems his home environment in Washington DC has a negative influence on his wellbeing. Unfortunately, it is difficult at this limited interaction to determine the exact situation which is problematic, although it may be related (conjecture) to a gang presence in his neighbourhood. 2. Describe probable stressors, triggering factors contributing to the client’s status. Include subjective and objective assessment information. His stressors are most likely related to academic settings. All chart based triggers, seem to involve DR’s home school. It is likely there are enumerable stressors in his daily life, but it is likely, as he has missed a lot of school, he is behind his cohort. His chart indicates an IQ test score in a range of 53 – 68 (WISC - IV). Nevertheless, the validity of this score must be questioned based on the psychometrist’s comments. Evidently, DR did not try many of the questions, and it was recommended that DR be given the measure again by a trusted adult to get a more reflective measure of his abilities. The unwillingness to complete this “pen and paper” task is in line with his avoidance of academic work in general. Daily stressor outside the classroom are likely high given his incomplete history. Making inferences from DR’s comments about “the streets”, his cousin being incarcerated, and his socio economic status, it is quite probable DR is at a high level of stress in his environment. This situation does not portend well for his future prospects, unless he manages to come to an improved day to day environment.